CPT® codes (99421-99423) – and payment for – online digital evaluation and management (E/M) services

New for 2020!

Be sure to read the telemedicine COVID-19 article for the latest information.

• CPT^® developed three new CPT^® codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform
• CMS is developing three new HCPCS codes for use by clinicians who do not have E/M within their scope of practice who have E/M services in their scope of practice, and will recognize these instead of new CPT^® codes 98970—98792
• CMS is requiring verbal consent for communication-based technology services (CBTS)
• This verbal consent is required annually, and encompasses all CBTS, not a consent/service or consent for each provision of the service
• These are not considered telehealth services, so do not use POS 02 and modifier 95. Why? they are not on CMS’s list of covered telehealth services, and do not use real-time, interactive audio-visual communication

New CPT® codes and CMS payment

In the 2020 CPT^® book, CPT deleted code 99444, which was defined as an online E/M service by a physician or other qualified health care professional. CPT^® is adding three new time-based codes for online evaluation and treatment, for use by clinicians who have E/M in their scope of practice, and three codes for use by clinicians who do not have E/M in their scope of practice, 98970-98972. To complicate matters, CMS will not recognize 98970-98972, but developed HCPCS codes for clinicians who do not have E/M in their scope.

New CPT^® codes for online digital E/M

99421 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422            11—20 minutes

99423            21 or more minutes

These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by clinicians who may independently bill an E/M service. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.

Report these services once during a 7-day period, for the cumulative time. According to CPT^®,

“The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician  or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.”[1]

Other requirements:

• Verbal consent is required by CMS.
• The patient initiates the service with an inquiry through the portal
• The service is documented in the medical record.
• If the patient had an E/M service within the last seven days, these codes may not be used for that problem.
• If the inquiry is about a new problem (from the problem addressed at the E/M service in the past 7 days), these codes may be billed.
• If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
• This is for established patients, per CPT^®.
• This may not be billed by surgeons during the global period.
• The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.

Additionally:

• These services may only be reported once in a 7-day period.
• Clinical staff time may not be included.
• Don’t double count time with any other separately reported services, such as care management, INR monitoring, remote monitoring. (CPT^® book has a list of codes)

Medicare is using HCPCS codes for clinicians without E/M in their scope of practice

Online services provided by clinicians who may not bill E/M services

CPT ^© codes for clinicians who do not have E/M services in their scope of practice, 98970—98972.  There is an editorial notation after codes 99421, discussed above, that says:

“For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), see 98970, 98971, 98972).”[2]

CMS, however, said in the 2020 Final Rule that they would not recognize these codes, because they are defined by CPT has “evaluation and management” services, and CMS reserves those words exclusively for physicians, advance practice nurse practitioners and physician assistants.  These codes have a status indicator of invalid in the Medicare fee schedule, and don’t have RVUs assigned to them.

98970 Qualified nonphysician health care professional online digital evaluation and management
service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971    11-20 minutes

98972   21 minutes or more

Medicare is using HCPCS codes for on-line digital evaluation performed by these professionals who can’t bill E/M services. Notice, that instead of “evaluation and management” the definitions use the word “assessment.”

G2061 (Qualified non-physician health care professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes);

G2062            11-20 minutes

G2063            21 or more minutes

The chart below does not include 98970—98972 because CMS has not assigned RVUs.

[1] CPT Professional Edition, 2020. AMA, Chicago, p. 68.

[2] CPT 2020 Professional Edition, AMA, Chicago 2020, page 40.

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